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According to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) , hospitals and nursing homes need to reconcile each patient’s current medication orders with the medications the patient has been taking in order to prevent potentially fatal errors. Reconciliation must be done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions.
According to the JCAHO Sentinel Event Alert, reconciliation should be done at every transition of care. Transitions in care include changes in setting, service, practitioner or level of care. The process includes five steps: 1) make a list of current medications; 2) make a list of medications to be prescribed; 3) compare the two lists; 4) make clinical decisions based on the comparison; and 5) communicate the new list to the providers and to the patient. Communication seems to be the key to patient safety.
A pharmacy at one hospital reported a reduction in potential adverse drug events of 80 percent when they required detailed medication histories for all patients scheduled for surgery.
You might be interested to learn that the Joint Commission’s sentinel event database includes more than 350 medication errors resulting in death or major injury. JCAHO believes half of those could have been avoided through effective medication reconciliation. Approximately, 63 percent involved problems with communication among providers.
The Institute for Safe Medication Practices (ISMP) has received many reports of medication reconciliation errors. Please click on ISMP above to review their Medication Safety Alert newsletter of April 21, 2005, which includes a sampling of such errors that resulted from failed communication.
Ask your doctor or nursing home administrator whether their facility has implemented this critical safety procedure.
